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Purpose of ReviewGlioblastoma remains resistant to most conventional treatments. Despite scientific advances in the past three decades, there has been a dearth of effective new treatments. New approaches to drug delivery and clinical trial design are needed.Recent FindingsWe discuss how the blood–brain barrier and tumor microenvironment pose challenges for development of effective therapies for glioblastoma. Next, we discuss treatments in development that aim to overcome these barriers, including novel drug designs such as nanoparticles and antibody–drug conjugates, novel methods of drug delivery, including convection-enhanced and intra-arterial delivery, and novel methods to enhance drug penetration, such as blood–brain barrier disruption by focused ultrasound and laser interstitial thermal therapy. Lastly, we address future opportunities, positing combination therapy as the best strategy for effective treatment, neoadjuvant and window-of-opportunity approaches to simultaneously enhance therapeutic effectiveness with interrogation of on-treatment biologic endpoints, and adaptive platform and basket trials as imperative for future trial design.SummaryNew approaches to GBM treatment should account for the blood-brain barrier and immunosuppression by improving drug delivery, combining treatments, and integrating novel clinical trial designs.

The term neurotranscriptomics is used here to describe genome-wide analysis of neural control of transcriptomes. In this report, next-generation RNA sequencing was using to analyze the effects of neonatal (5-days-of-age) surgical stimulus deprivation on the adult rat pineal transcriptome. In intact animals, more than 3000 coding genes were found to exhibit differential expression (adjusted-p < 0.001) on a night/day basis in the pineal gland (70% of these increased at night, 376 genes changed more than 4-fold in either direction). Of these, more than two thousand genes were not previously known to be differentially expressed on a night/day basis. The night/day changes in expression were almost completely eliminated by neonatal removal (SCGX) or decentralization (DCN) of the superior cervical ganglia (SCG), which innervate the pineal gland. Other than the loss of rhythmic variation, surgical stimulus deprivation had little impact on the abundance of most genes; of particular interest, expression levels of the melatonin-synthesis-related genes Tph1, Gch1, and Asmt displayed little change (less than 35%) following DCN or SCGX. However, strong and consistent changes were observed in the expression of a small number of genes including the gene encoding Serpina1, a secreted protease inhibitor that might influence extracellular architecture. Many of the genes that exhibited night/day differential expression in intact animals also exhibited similar changes following in vitro treatment with norepinephrine, a superior cervical ganglia transmitter, or with an analog of cyclic AMP, a norepinephrine second messenger in this tissue. These findings are of significance in that they establish that the pineal-defining transcriptome is established prior to the neonatal period. Further, this work expands our knowledge of the biological process under neural control in this tissue and underlines the value of RNA sequencing in revealing how neurotransmission influences cell biology.

Abstract BACKGROUND Appropriate thrombus-device interaction is critical for recanalization. Histology can serve as a proxy for mechanical properties, and thus inform technique selection. OBJECTIVE To investigate the value of histologic characterization, we conducted a systematic review and meta-analysis on the relationship between thrombus histology and recanalization, technique, etiology, procedural efficiency, and imaging findings. METHODS In this meta-analysis, we identified studies published between March 2010 and March 2020 reporting findings related to the histologic composition of thrombi in large vessel occlusion stroke. Studies with at least 10 patients who underwent mechanical thrombectomy using stent retriever or aspiration were considered. Only studies in which retrieved thrombi were histologically processed were included. Patient-level data were requested when data could not be directly extracted. The primary outcome assessed was the relationship between thrombus histology and angiographic outcome. RESULTS A total of 22 studies encompassing 1623 patients met inclusion criteria. Clots associated with good angiographic outcome had higher red blood cell (RBC) content (mean difference [MD] 9.60%, 95% CI 3.85-15.34, P = .008). Thrombi retrieved by aspiration had less fibrin (MD −11.39, 95% CI −22.50 to −0.27, P = .046) than stent-retrieved thrombi. Fibrin/platelet-rich clots were associated with longer procedure times (MD 13.20, 95% CI 1.30-25.10, P = .037). Hyperdense artery sign was associated with higher RBC content (MD 14.17%, 95% CI 3.07-25.27, P = .027). No relationship was found between composition and etiology. CONCLUSION RBC-rich thrombi were associated with better recanalization outcomes and shorter procedure times, suggesting that preinterventional compositional characterization may yield important prognostic and therapeutic guidance.

Intraplaque hemorrhage (IPH) in carotid atherosclerosis demonstrates increased signal on magnetic resonance angiography images. Little remains known about how this signal changes on subsequent examinations. A retrospective observational study was completed of patients that had IPH on a neck MRA between 1/1/2016 and 3/25/2021, defined as ≥ 200 % signal intensity of the sternocleidomastoid muscle on MPRAGE images. Examinations were excluded if the patients had undergone carotid endarterectomy between examinations or had poor quality imaging. IPH volumes were calculated by manually outlining IPH components. Up to 2 subsequent MRAs, if available, were assessed for both the presence and volume of IPH. 102 patients were included, of which 90 (86.5 %) were male. IPH was on the right in 48 patients (average volume = 174.0 mm3), and on the left in 70 patients (average volume 186.9 mm3). 22 had at least one follow-up (average 444.7 days between exams), and 6 had two follow-up MRAs (average 489.5 days between exams). On the first follow-up, 19 (86.4 %) plaques had persistent hyperintense signal in the region of IPH. The second follow-up showed persistent signal in 5/6 plaques (88.3 %). Combined volume of IPH from right and left carotid arteries did not significantly decrease on the first follow-up exam (p = 0.08). IPH usually retains hyperintense signal on follow-up MRAs, possibly representing recurrent hemorrhage or degraded blood products. •In carotid artery plaques, intra-plaque hemorrhage (IPH) typically retains hyperintense signal on follow-up MRA imaging.•This is thought to represent recurrent hemorrhage and/or degraded blood products.•Although IPH volume changes are less predictable over time, they tend to decrease on follow-up exams.

Background This study characterized vessel wall imaging (VWI) features of Moyamoya disease (MMD) in a predominantly adult population at a North American center. Methods Consecutive patients with VWI were included. Twelve arterial segments were analyzed for wall thickening, degree and pattern of contrast enhancement, and remodeling. Results Overall, 286 segments were evaluated in 24 patients (mean age = 36.0 years [range = 1–58]). Of 172 affected segments, 163 (95%) demonstrated negative remodeling. Complete vessel wall obliteration was most frequent in the proximal M1 (17/48, 35%). Affected segments enhanced in 72/172 (42%) (n = 15 for grade II; n = 54 for concentric and n = 18 for eccentric); 20 of 24 (83%) patients had at least one enhancing segment. Both enhancing and non-enhancing segments were present in 19/20 (95%) patients. Vessel wall enhancement was most common in the proximal segments and correlated to the degree of stenosis ( p  < 0.001), and outer wall diameter ( p  < 0.001), but not disease duration ( p  = 0.922) or Suzuki score ( p  = 0.477). Wall thickening was present in 82/172 (48%) affected segments and was associated with contrast enhancement ( p  < 0.001), degree of stenosis ( p  < 0.001), and smaller outer wall diameter ( p  = 0.004). Conclusion This study presents VWI findings in North American patients with MMD. Negative remodeling was the most common finding. Most patients had both enhancing and non-enhancing abnormal segments. Vessel wall enhancement was most common in proximal segments, variable in pattern or degree and was correlated to the degree of stenosis and smaller outer wall diameter.

Background Little is known about the association between carotid artery tortuosity and internal carotid artery atherosclerosis. This study sought to evaluate the associations between various types of arterial tortuosity and vulnerable plaque components on magnetic resonance angiography (MRA). Material and Methods A retrospective review was completed of 102 patients who had undergone MRA neck imaging, with intraplaque hemorrhage (IPH) present in one or both cervical internal carotid arteries (ICA). Each ICA was assessed for two categories of tortuosity: variant arterial pathway(s) (retrojugular and/or retropharyngeal) and abnormal curvature (kinks, loops, and/or coils). All ICA plaques were assessed for the presence or absence of intraplaque hemorrhage (IPH), lipid-rich necrotic core (LRNC), ulceration, and enhancement, as well as the volume of IPH and degree of luminal stenosis. Results The mean age of included patients was 73.5 years (SD = 9.0 years) and 88 (86.3%) subjects were male. The left carotid plaque was significantly more likely to have IPH (68.6% vs. 47.1%; p  = 0.02). The left ICA was more likely to have a retrojugular course (22% vs. 9.9%; p  = 0.002) and any variant arterial course (26.5% versus 14.67%, p  = 0.01). On the right there was an association between the presence of a LRNC and retropharyngeal and/or retrojugular arterial pathway ( p  = 0.03). On the left there was an association between the presence of any abnormal arterial curvature and IPH volume ( p  = 0.03). Neither association met the adjusted statistical threshold after Bonferroni correction, with alpha set at 0.0028. Conclusion ICA tortuosity is not associated with carotid artery plaque composition, and likely does not play a role in the development of high-risk plaques.

BackgroundMechanical thrombectomy (MT) has become standard for large vessel occlusions, but rates of complete recanalization are suboptimal. Previous reports correlated radiographic signs with clot composition and a better response to specific techniques. Therefore, understanding clot composition may allow improved outcomes.MethodsClinical, imaging, and clot data from patients enrolled in the STRIP Registry from September 2016 to September 2020 were analyzed. Samples were fixed in 10% phosphate-buffered formalin and stained with hematoxylin-eosin and Martius Scarlett Blue. Percent composition, richness, and gross appearance were evaluated. Outcome measures included the rate of first-pass effect (FPE, modified Thrombolysis in Cerebral Infarction 2c/3) and the number of passes.ResultsA total of 1430 patients of mean±SD age 68.4±13.5 years (median (IQR) baseline National Institutes of Health Stroke Scale score 17.2 (10.5–23), IV-tPA use 36%, stent-retrievers (SR) 27%, contact aspiration (CA) 27%, combined SR+CA 43%) were included. The median (IQR) number of passes was 1 (1–2). FPE was achieved in 39.3% of the cases. There was no association between percent histological composition or clot richness and FPE in the overall population. However, the combined technique resulted in lower FPE rates for red blood cell (RBC)-rich (P<0.0001), platelet-rich (P=0.003), and mixed (P<0.0001) clots. Fibrin-rich and platelet-rich clots required a higher number of passes than RBC-rich and mixed clots (median 2 and 1.5 vs 1, respectively; P=0.02). CA showed a trend towards a higher number of passes with fibrin-rich clots (2 vs 1; P=0.12). By gross appearance, mixed/heterogeneous clots had lower FPE rates than red and white clots.ConclusionsDespite the lack of correlation between clot histology and FPE, our study adds to the growing evidence supporting the notion that clot composition influences recanalization treatment strategy outcomes.

BackgroundEmbolization of the middle meningeal artery (MMA) is a promising minimally invasive technique that is gaining traction in the treatment of chronic subdural hematoma. Unfortunately, the human meninges and associated arteries are significantly larger than those of conventional laboratory animals, making the development of a clinically relevant animal model for testing of embolization agents elusive.ObjectiveTo introduce the posterior intercostal artery (PIA) model in swine and provide anatomical, angiographic, histological, and procedural data to validate its relevance in modeling the human MMA.MethodsIn human cadaveric specimens, 3D angiograms of the internal maxillary arteries (n=6) were obtained and the dura with MMA were harvested and histologically processed. Angiographic and histologic data of the human MMA were compared with the swine PIA (three animals). Then, embolization of the PIA (n=48 arteries) was conducted with liquid embolization agent (Onyx, Medtronic), and angiographic and histological results were assessed acutely (four animals) and after 30 days (two animals).ResultsThe human MMA has equivalent diameter, length, branching pattern, 3D trajectory, and wall structure to those of swine PIAs. Each swine has 12 to 14 PIAs (6–7 per side) suitable for acute or chronic embolization, which can be performed with high fidelity using the same devices, agents, and techniques currently used to embolize the MMA. The arterial wall structure and the acute and chronic histological findings in PIAs after embolization are comparable to those of humans.ConclusionsThis PIA model in swine could be used for research and development; objective benchmarking of agents, devices, and techniques; and in the training of neurointerventionalists.

ObjectiveTo systematically analyse prior reports of carotid endarterectomy (CEA) performed in cases of ≤50% carotid stenosis in order to understand patient tolerance and potential benefit.MethodsA systematic review and descriptive analysis was performed in concordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. An English-language search was performed of online databases using librarian-selected search terms. Abstracts were reviewed for relevance which included mention of carotid endarterectomy and stenosis. Prospective or retrospective observational cohort studies that reported series of patients who underwent endarterectomy for minimal (≤50%) luminal stenosis with reported outcomes were included.ResultsSix studies (which included our institutional series) with a total of 143 patients met the inclusion criteria. The weighted mean age at the time of CEA was 72.3 years; 113 (79.0%) were male. 55.8% of patients with available data had recurrent ipsilateral ischaemic events despite medical therapy. Two patients out of 129 with available perioperative data (1.6%) had perioperative MRI findings of acute ischaemic stroke, both within the hemisphere contralateral to the side of CEA. Of the 138 patients with available follow-up (mean, 36 months), none had recurrent ipsilateral ischaemic events.ConclusionsEndarterectomy for symptomatic carotid disease causing ≤50% stenosis may be a potentially beneficial strategy to prevent stroke recurrence. Studies with robust methodology are needed to draw more definitive conclusions in terms of the safety and efficacy of endarterectomy for minimal stenosis with vulnerable features relative to intensive medical therapy.